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PROOF OF INSURANCE (2022 - 2022) CLOSEDVENDI-1 ACOROPo CERTIFICATE OF LIABILITY INSURANCE D YY) 03 231202 03l2312022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER 310-282-0900 ra C ACT Shahrad Nahal Naha! Insuran 466 S. BeverlycDri #200 Inc. _._ 310 282 0900 LF 31, PHONE 0 282-0976 e, Beverly Hills, CA 90212 Shahrad Nahai Y(1SUReF SI,EDING COVERAGE ._ NA9,C # ... _LN§IIRERArUSLI - United States Liability 25895 INSURED Vendingg 26 Inc. __-... s. 504 N Hillcrest Rd R......�_..-_--___ jNsu, Fr ..______________—_----._ Beverly Hills, CA 90210 INSURER Q INSURER E INSURER F COVERAGES CE IFIC 'T NI E I IONNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, AND CONDITIONS OF SUCH BEEN REDUCEDBYPAID CLAIMS. LIMITS SHPoucY rNSXCLUSIONS NUM ERVE noDLsiia' Uq POLICY EXP L*MTYPE OF INSURANCE LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X DccuR _ ❑ X CL 1908399C 12/18/2021 12/18/2022 DAMAGE TO RENTED u p(ak $,,,,_ 300 000„ 10,000 MED EXPny one (Aperson $ 7..... ___. .—__.__.. PERSONAL & ADV INJURY _. ..... $ 1,000,000 ._ .,. GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGA TE $ 2,000,000.. " LOC ❑ .. � _ ...... .__ 2,000,000 . JET I� C F „PRODIIC�T, COMP/(�1P,AqG A. OTHER: $ AUTOMOBILE LIABILITY NED SINGLE. LIMIT .C9 MB6NE0SI lP, ..,..,.. ..,._._. $ �--�...... ANY AUTO _....... (.P?.{,.(?Prscln, ..��.$ .��'��.�.�..... OWNED SCHEDULED _ . AUTOS ONLY AUTOS 6IN L RY (E.P.r apc catn ? _.9,.,......... ..--- HIRED NO.VTNN �py R0011 g Y1C ANttACaE.....,.,.. —_..., AUTOS ONLY .....,m. O Y i 3 eP, cd .......,.,,m $ UMBRELLA LIAB OCCUR EACH _OCCLIRR,ENCF . ........................................ $ ....................... ........... _.._. ............. CLAI S MADE _.EXCESS.,LIAB............._..............................-............. AGGREGATE ....-._..._.._.................m.............�_ $.................,..... ._....w..........-.................................................... DED RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY .... ;STA:7.LlT .........E,R H .� .. .. Yl,q ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E L EACH ACCIDENT - 5 - •• - (Mandatory in NH) E.L. DISEASE- EA EMPLOYE $ If yes, describe under 1 RIPTION F P R,ATICN beI wu ......E L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Molder is Included as Additional Insured as respects to the operations of the Named Insured. Coverage is subject to policy terms, conditions, limitations, and exclusions. City Of El Segundo 350 Main Street El Segundo, CA 90245 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE s4-Ai"' IvQ_ ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD PROGRESSIVE P.O. BOX 31260 TAMPA, FL 33631 NAIC Company Code: 11770 It "Verification of Insurance for Bruno M Uzzan and 998REW' DIRECT Auto Policy Number: 10386405 Underwritten by: United Financial Cas Co Policyholders: Bruno M Uzzan Page 1 of 2 March 23, 2022 Customer Service 1-800-776-4737 24 hours a day, 7 days a week This verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this verification of insurance may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of the policies. Please accept this letter as verification of insurance for this policy. Policy and driver information Policy number: 10386405 ....................................................................................................... Policy state: . .. California ....................................................... Policy period: .Dec 5, 2021 fun 5, 2022 There was no lapse in coverage during this polity period. Effective date: ......................................... Dec 5, 2021 Drivers: Bruno M Uzzan 1,ns.,..,.,,..,.,,,.,..,,.,.....,.. ured Driver Insured Driver Address: .............................. — 504 N Hillcrest rd Beverly Hills, CA 90210 Vehicle information ....................................... Vehicle: ...eh.......i icle..dentif....i... ca..t.ion.......number:........ V .......... ................. . .......... Lienholder: Coverage information ...................................... Liability To Others Bodily Injury Liability Property Damage Liability ..—.....,..,.. 019 CHEVROLET BOLT GM FINANCIAL PO Box 1617 MINNEAPOLIS, MN 55440 $50,000 each person/$100,000 each accident $25,000 each accident Form V01 (07/13) ConYigni Additional interest GM FINANCIAL PO Box 1617 MINNEAPOLIS, MN 55440 Policy Number: 10386405 Underwritten by: United Financial Cas Co Policyholders: Bruno M Uzzan Page 2 of 2 March 23, 2022 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CRIMINALION PENALAGE TIES ES IS UNLAWFUL AND SUBJECTS AN EMPLOYER AND CIVIL FINES UP TO ONE HUNDRED THOUSAND OLLARS AS PROVIDED, IN ADDITION TO THE COST OF COMPENSATION, FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. I affirm under penalty of perjury under the laws of California one of the following declarations: U I have and will maintain a certificate of consent of self -insure for workers' compensation, issued by the Director of Industrial Relations as provided for by Labor Code § 3700 for the performance of the work set forth the agreement with the City of El Segundo. Policy No. (� I have and will maintain workers' compensation insurance as required by Labor Code § 3700 for the per of the work for which the agreement with the City of El Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier Policy Number Expiration Date Name of Agent Phone # ( I certify that, in the performance of the work set forth in the agreement with the City of El Segundo, I will not employ any person in any manner so as to become subject to the workers" compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement wl", u o all ecome void. Signature of Applicant Date r nA, ementfor: Agre .. - �.... Dated: 1 Reviewed by:�